The Peripheral Vascular System

ANATOMY AND PHYSIOLOGY

Careful assessment of the peripheral vascular system is essential for
detection of peripheral arterial disease, found in approximately 30% of the
adult population, but silent in roughly half of those affected.
1

hromboembolic disorders of the peripheral venous system are also
common, seen in an estimated 1% of adults older than !0 years, and early
detection is critical to minimi"ing ris# of fatal pulmonary embolism.
$

his chapter revie%s the anatomy and physiology of the arteries, veins, and
lymphatic system in the arms and legs, and updates health history ta#ing,
health promotion and counseling, and techni&ues of examination according
to the 'merican College of Cardiology and 'merican (eart 'ssociation
$00) *ractice +uidelines for the ,anagement of *atients %ith *eripheral
'rterial -isease.
3

ARTERIES
'rteries contain three concentric layers of tissue. the intima, the media, and
the adventitia.
/n0ury to vascular endothelial cells can provo#e thrombus formation,
atheromas, and the vascular lesions of hypertension.
1

2urrounding the lumen of all blood vessels is the intima, a single continuous
lining of endothelial cells %ith remar#able metabolic properties.
1
/ntact
endothelium synthesi"es regulators of thrombosis li#e prostacyclin,
plasminogen activator, and heparin3li#e molecules. /t produces
prothrombotic molecules such as 4on 5illebrand factor and plasminogen
activator inhibitor. /t modulates blood flo% and vascular reactivity through
synthesis of vasoconstrictors li#e endothelin and angiotensin3converting
en"yme and vasodilators such as nitric oxide and prostacyclin. he intimal
endothelium also regulates immune and inflammatory reactions through
elaboration of interleu#ins, adhesion molecules, and histocompatibility
antigens.
67',*862 9: ';<9=,'8//62
'n atheroma begins in the intima as lipid3filled foam cells, then fatty
strea#s. Complex atheromas are thic#ened asymmetric pla&ues that narro%
the lumen, reducing blood flo%, and %ea#en the underlying media. hey
have a soft lipid core and a fibrous cap of smooth muscle cells and a
collagen3rich matrix. *la&ue rupture may precede thrombosis.
1
,
)
he media is composed of smooth muscle cells that dilate and constrict to
accommodate blood pressure and flo%. /ts inner and outer boundaries are
membranes of elastic fibers, or elastin, called internal and external elastic
laminae. 2mall arterioles called the vasa vasorum perfuse the media. he
outer layer of the artery is the adventitia, connective tissue containing nerve
fibers and the vasa vasorum.
8ayers of the 'rtery. >/nside to 9utside?
unica /ntima @ 8ayers of 6ndothelial cells, 4asodilators and 4asoconstrictors
unica ,edia@ 2mooth muscle cells > -ilate and constrict for blood pressure and
flo%. 4asa vasorum
'dventitia @ 8ayers of Connective tissue containing nerve fibers and 4asa
vasorum.
'rterial pulses are palpable in arteries lying close to the body surface. /n the
arms, note pulsations in.
A he brachial artery at the bend of the elbo% 0ust medial to the biceps
tendon
A he radial artery on the lateral flexor surface, and
A he ulnar artery on the medial flexor surface, although overlying tissues
may obscure the ulnar artery
'rterial *ulses
;rachial 'rtery @ ,edial o ;iceps endon
=adial 'rtery @ 8ateral flexor surface
Blnar 'rtery @ ,edial :lexor 2urface
%o vascular arches %ithin the hand interconnect the radial and ulnar
arteries, doubly protecting circulation to the hand and fingers against
possible arterial occlusion.
'rteries must respond to the variations that cardiac systole and diastole
generate in cardiac output. heir anatomy and si"e vary according to
their distance from the heart. he aorta and its immediate branches are large
or highly elastic arteries such as the pulmonary, common carotid, and iliac
arteries. hese arteries course into medium3si"ed or muscular arteries li#e
the coronary and renal arteries. he elastic recoil and smooth muscle
contraction and relaxation in the media of large and medium3si"ed arteries
propagate arterial pulsatile flo%. ,edium3si"ed arteries divide into small
arteries less than $ mm in diameter and even smaller arterioles %ith
diameters from $0 to 100 mm. =esistance to blood flo% occurs primarily in
the arterioles. >=ecall that resistance is inversely proportional to the fourth
po%er of the vessel diameter, #no%n as the la% of 8a*lace.
1
:rom the
arterioles blood flo%s into the vast net%or# of capillaries, each the diameter
of a single red blood cell, only C to D microns >Em? across. Capillaries have
an endothelial cell lining but no media, facilitating rapid diffusion of oxygen
and carbon dioxide.
/n the legs, find pulsations in.
he femoral artery 0ust belo% the inguinal ligament, mid%ay bet%een
the anterior superior iliac spine and the symphysis pubis
he popliteal artery, an extension of the femoral artery that passes
medially behind the femur, palpable 0ust behind the #nee. he
popliteal artery divides into the t%o arteries perfusing the lo%er leg
and foot, namely F
he dorsalis pedis artery on the dorsum of the foot 0ust lateral to the
extensor tendon of the big toe, and
he posterior tibial artery behind the medial malleolus of the an#le.
'n interconnecting arch bet%een its t%o chief arterial branches
protects circulation to the foot.
9* to ;99, .
:emoral 'rtery @G *opliteal 'rtery @ -orsalis *edis and *osterior tibial
'rtery
46/<2
Bnli#e arteries, veins are thin3%alled and highly distensible, %ith a capacity
for up to t%o3thirds of circulating blood flo%. he venous intima consists of
nonthrombogenic endothelium. *rotruding into the lumen are valves that
promote unidirectional venous return to the heart. he media contains
circumferential rings of elastic tissue and smooth muscle that change vein
caliber in response to even minor changes in venous pressure.
1
,
!

4eins from the arms, upper trun#, and head and nec# drain into the superior
vena cava, %hich empties into the right atrium. 4eins from the legs and
lo%er trun# drain up%ard into the inferior vena cava. ;ecause of their
%ea#er %all structure, the leg veins are susceptible to irregular dilatation,
compression, ulceration, and invasion by tumors and %arrant special
attention.
Deep an Super!icial Ven"us System #Le$s%&
he deep veins of the legs carry approximately H0% of venous return from
the lo%er extremities. hey are %ell supported by surrounding tissues.
/n contrast, the superficial veins are subcutaneous, %ith relatively poor tissue
support. hey include.
A he great saphenous vein, %hich originates on the dorsum of the foot,
passes 0ust anterior to the medial malleolus, continues up the medial aspect
of the leg, and 0oins the femoral vein of the deep venous system belo% the
inguinal ligament
A he small saphenous vein, %hich begins at the side of the foot, passes
up%ard along the posterior calf, and 0oins the deep venous system in the
popliteal fossa
'nastomotic veins connect the t%o saphenous veins that are readily visible
%hen dilated. ;ridging or perforating veins connect the superficial system
%ith the deep system.
5hen competent, the one3%ay valves of the deep, superficial, and
perforating veins propel blood to%ard the heart, preventing pooling, venous
stasis, and bac#%ard flo%. Contraction of the calf muscles during %al#ing
also serves as a venous pump, s&uee"ing blood up%ard against gravity.
'rteries @ '5'I from the (eart > :emoral,*opliteal, *osterior ibial.
-orsalis *edis 'rteries?
4eins @ 95'=-2 the (eart > 2uperficial 4eins @ +reat and 2mall
2aphenous 4ein?
THE LYMPHATI' SYSTEM AND LYMPH NODES
he lymphatic system is an extensive vascular net%or# that drains lymph
fluid from body tissues and returns it to the venous circulation. he system
starts peripherally as blind lymphatic capillaries, continues centrally as thin
vascular channels, then collecting ducts, and empties into the ma0or veins at
the nec#. 8ymph fluid transported through these channels is filtered through
lymph nodes interposed along the %ay.
8ymph nodes are round, oval, or bean3shaped structures that vary in si"e
according to their location. 2ome lymph nodes, such as the preauriculars, if
palpable at all, are typically very small. he inguinal nodes, in contrast, are
relatively largerJoften 1 cm in diameter and occasionally even $ cm in an
adult.
/n addition to its vascular functions, the lymphatic system plays an important
role in the bodyKs immune system. Cells %ithin the lymph nodes engulf
cellular debris and bacteria and produce antibodies.
9nly the superficial lymph nodes are accessible to physical examination.
hese include the cervical nodes ,the axillary nodes and nodes in the arms
and legs.
=ecall that the axillary lymph nodes drain most of the arm. 8ymphatics from
the ulnar surface of the forearm and hand, the little and ring fingers, and the
ad0acent surface of the middle finger, ho%ever, drain first into the
epitrochlear nodes. hese are located on the medial surface of the arm
approximately 3 cm above the elbo%. 8ymphatics from the rest of the arm
drain mostly into the axillary nodes. ' fe% may go directly to the
infraclaviculars.
he lymphatics of the lo%er limb, follo%ing the venous supply, consist of
both deep and superficial systems. 9nly the superficial nodes are palpable.
he superficial inguinal nodes include t%o groups. he hori"ontal group lies
in a chain high in the anterior thigh belo% the inguinal ligament. /t drains the
superficial portions of the lo%er abdomen and buttoc#, the external genitalia
>but not the testes?, the anal canal and perianal area, and the lo%er vagina.
he vertical group clusters near the upper part of the saphenous vein and
drains a corresponding region of the leg. /n contrast, lymphatics from the
portion of leg drained by the small saphenous vein >the heel and outer aspect
of the foot? 0oin the deep system at the level of the popliteal space. 8esions
in this area, therefore, are not usually associated %ith palpable inguinal
lymph nodes.
(L)ID E*'HANGE AND THE 'APILLARY +ED
;lood circulates from arteries to veins through the capillary bed. (ere fluids
diffuse across the capillary membrane, maintaining a dynamic e&uilibrium
bet%een the vascular and interstitial spaces. ;lood pressure >hydrostatic
pressure? %ithin the capillary bed, especially near the arteriolar end, forces
fluid out into the tissue spaces. his movement is aided by the relatively
%ea# osmotic attraction of proteins %ithin the tissues >interstitial colloid
oncotic pressure? and is opposed by the hydrostatic pressure of the tissues.
's blood continues through the capillary bed to%ard the venous end, its
hydrostatic pressure falls, and another force gains dominance. his is the
colloid oncotic pressure of plasma proteins, %hich pulls fluid bac# into the
vascular tree. <et flo% of fluid, %hich %as directed out%ard on the arteriolar
side of
the capillary bed, reverses and turns in%ard on the venous side. 8ymphatic
capillaries, %hich also play an important role in this e&uilibrium, remove
excessive fluid, including protein, from the interstitial space.
8ymphatic dysfunction or disturbances in hydrostatic or osmotic forces can
all disrupt this e&uilibrium. he most common clinical result is the increased
interstitial fluid #no%n as edema >see able 1$3), *eripheral Causes of
6dema, p. 1HH?.
(6 (6'8( (/29=I
Common or Concerning 2ymptoms
*ain in the arms or legs
/ntermittent claudication
Cold, numbness, pallor in the legsL hair loss
2%elling in calves, legs, or feet
Color change in fingertips or toes in cold %eather
2%elling %ith redness or tenderness
's defined by recent guidelines from the 'merican College of Cardiology
and the 'merican (eart 'ssociation, peripheral arterial disease >*'-? refers
to stenotic, occlusive, and aneurysmal disease of the aorta, its visceral
arterial branches, and the arteries of the lo%er extremities, exclusive of the
coronary arteries.
3
;e a%are that pain in the extremities may arise from the
s#in, peripheral vascular system, musculos#eletal system, or nervous system.
/t also may be referred, li#e the pain of myocardial infarction that radiates to
the left arm.
2ee able 1$31, *ainful *eripheral 4ascular -isorders and heir ,imics, pp.
1H131H).
's# about any pain or cramping in the legs during exertion that is relieved
by rest %ithin 10 minutes, termed intermittent claudication.
67',*862 9: ';<9=,'8//62
'therosclerosis can cause symptomatic limb ischemia %ith exertionL
distinguish this from spinal stenosis, %hich produces leg pain %ith exertion
that may be reduced by leaning for%ard >stretching the spinal cord in the
narro%ed vertebral canal? and less readily relieved by rest.
's# also about coldness, numbness, or pallor in the legs or feet or loss of
hair over the anterior tibial surfaces.
67',*862 9: ';<9=,'8//62
(air loss over the anterior tibiae occurs %ith decreased arterial perfusion.
-ry or bro%n3blac# ulcers from gangrene may ensue.
;ecause most patients %ith *'- report minimal symptoms, as#ing
specifically about the symptoms that follo% is recommended, especially in
patients older than )0 years and those %ith ris# factors, especially smo#ing
but also diabetes, hypertension, elevated cholesterol, or coronary artery
disease >see p. 31$?.
3

*.1CD
5hen symptoms >see belo%? or ris# factors are present, careful examination
and testing of the an#le3brachial index are %arranted >see p. 1CH and p. 1H!?.
67',*862 9: ';<9=,'8//62
9nly about 10% of patients have the classic triad of leg pain %ith exertion
that stops %ith rest.
1
he lo% symptom rate may reflect functional declines
in %al#ing, even though *'- is present or progressing.
C

A :atigue, aching, numbness, or pain that limits %al#ing or exertion in the
legsL if present, identify the location. 's# also about erectile dysfunction.
67',*862 9: ';<9=,'8//62
2ymptom location suggests the site of arterial ischemia.
A buttoc#, hip. aortoiliac
A erectile dysfunction. iliacpudendal
A thigh. common femoral or aortoiliac
A upper calf. superficial femoral
A lo%er calf. popliteal
A foot. tibial or peroneal
A 'ny poorly healing or nonhealing %ounds of the legs or feet
A 'ny pain at rest in the lo%er leg or foot and changes %hen standing or
supine
A 'bdominal pain after meals and associated food fear and %eight loss
67',*862 9: ';<9=,'8//62
'bdominal pain, food fear, and %eight loss suggest intestinal ischemia of
the celiac or superior or inferior mesenteric arteries.
A 'ny first3degree relatives %ith an abdominal aortic aneurysm
67',*862 9: ';<9=,'8//62
*revalence of abdominal aortic aneurysms in first3degree relatives is 1)% to
$D%.
3

(6'8( *=9,9/9< '<- C9B<268/<+
/mportant opics for (ealth *romotion and Counseling
2creening for peripheral arterial disease >*'-?L the an#le3brachial
index >';/?
2creening for renal artery disease
2creening for abdominal aortic aneurysms
2creening for *eripheral 'rterial -isease. he 'n#le3;rachial /ndex.
*'- is a common manifestation of atherosclerosis, affecting from 1$% to
$H% of community populations.
1
,
D
*revalence of *'- increases %ith age
and the
*.1CH
presence of cardiovascular ris# factors. *revalence by age group rises from
$.)% in patients !0 years or older, to D% in those !03!H years, and 1H% in
those C0 years or older.
H
*'- and cardiovascular disease overlap in 1!% of
patients.
1
-espite %idespread prevalence, *'- is underdiagnosed in office
practices.
1
,
3
,
10
'lthough the B.2. *reventive 2ervices as# :orce does not
advocate screening, the 'merican College of CardiologyM'merican (eart
'ssociation guidelines support case3finding in those at ris#, as detailed
belo%.
3

RIS, (A'TORS (OR LO-ER.E*TREMITY PERIPHERAL
ARTERIAL DISEASE
'ge younger than )0 years %ith diabetes or atherosclerosis ris# factor
of smo#ing, dyslipidemia, hypertension, or hyperhomocysteinemia
'ge )0 to !H years and history of smo#ing or diabetes
'ge C0 years or older
8eg symptoms %ith exertion or ischemic rest pain
'bnormal lo%er extremity pulses
Nno%n atherosclerotic coronary, carotid, or renal artery disease
>2ource. (irsch ', (as#al OP, (ert"er <=, et al. 'CCM'(' $00)
guidelines for the management of patients %ith peripheral arterial disease.?
8earn to assess for *'- by using the an#le3brachial index >';/?. he ';/ is
reliable, reproducible, and easy to perform in the office, %ith a sensitivity
and specificity of H0% and H)%, respectively.10 Clinicians or office staff
can readily measure systolic blood pressure in the arms and in the pedal
pulses, using -oppler ultrasound. hese values can be entered into
calculators readily available at selected 5eb sites >see 'merican College of
*hysicians, at http.MMcpsc.acponline.orgMenhancementsM$3$abiCalc.html?.
2ee able 1$3$, Bsing the 'n#le3;rachial /ndex, p. 1H!.
' %ide range of interventions is available to reduce both onset and
progression of *'-, including meticulous foot care and %ell3fitting shoes,
tobacco cessation, treatment of hyperlipidemia, optimal control and
treatment of diabetes and hypertension, use of antiplatelet agents, graded
exercise, and, if needed, surgical revasculari"ation.
11
*atients %ith ';/s in
the lo%est category have a $0% to $)% annual ris# for death.
1

2creening for =enal 'rtery -isease.
'therosclerotic renal artery disease affects C% of adults older than !) years,
rising to $$% to ))% of those %ith *'- and 30% of patients %ith
documented coronary artery disease.
3
,
1$
he 'merican College of
Cardiology and the 'merican (eart 'ssociation recommend diagnostic
studies for renal artery disease, usually beginning %ith ultrasound, in
patients %ith the follo%ing conditions. hypertension before 30 yearsL severe
hypertension >see p. 11D? after )) yearsL accelerated, resistant, or malignant
hypertensionL ne% %orsening of renal function or %orsening after use of an
angiotensin3converting en"yme inhibitor or an
*.1D0
angiotensin3receptor bloc#ing agentL an unexplained small #idneyL or sudden
unexplained pulmonary edema, especially in the setting of %orsening renal
function.
3
2ymptoms arise from these conditions rather than directly from
atherosclerotic changes in the renal artery.
2creening for 'bdominal 'ortic 'neurysm.
=ecent evidence documents the benefit of early detection of abdominal
aortic aneurysm >'''?, the 11th leading cause of death in the Bnited
2tates.
13
'n ''' is present %hen the infrarenal aortic diameter exceeds 3.0
cm. =upture and mortality rates dramatically increase for '''s exceeding
).) cm in diameter. he strongest ris# factor for rupture is excess aortic
diameter. 'dditional ris# factors are smo#ing, age older than !) years,
family history, coronary artery disease, *'-, hypertension, and elevated
cholesterol level. ;ecause symptoms are rare, and screening is no% sho%n to
reduce mortality by 10%, the B.2. *reventive 2ervices as# :orce
recommends one3time screening by ultrasound in men bet%een !) and C)
years %ith a history of ever smo#ing, defined as more than 100 cigarettes
in a lifetime.
11
-ue to lo%er prevalence, data on benefits of screening
nonsmo#ers and %omen are inconclusive. Bltrasound in asymptomatic
individuals is H)% sensitive and nearly 100% specific for '''.
*.1D1
6C(</QB62 9: 67',/<'/9<
/mportant 'reas of 6xamination
(6 '=,2
2i"e, symmetry, s#in color
=adial pulse, brachial pulse
6pitrochlear lymph nodes
(6 86+2
2i"e, symmetry, s#in color
:emoral pulse and inguinal lymph nodes
*opliteal, dorsalis pedis, and posterior tibial pulses
*eripheral edema
he 'merican College of Cardiology and the 'merican (eart 'ssociation
have urged clinicians to intensify their focus %hen examining the peripheral
vascular system.
3
=ecall that peripheral arterial disease is often
asymptomatic and underdiagnosed, leading to significant morbidity and
mortality. 's you learn and practice the techni&ues of the vascular
examination, observe the $00) recommendations for examining the
peripheral arterial system. =evie% the techni&ues for assessing blood
pressure, the carotid artery, the aorta, and the renal and femoral arteries on
the pages indicated belo%.
Summary/ ,ey '"mp"nents "! the Peripheral Arterial E0aminati"n
,easure blood pressure in both arms >see Ch. 1, pp. 11!311C?.
*alpate carotid upstro#e, auscultate for bruits >see Ch. H, p. 3)3?.
'uscultate for aortic, renal, and femoral bruitsL palpate aorta and
determine maximal diameter >see Ch. 11, pp. 13!313C?.
*alpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and
posterior arteries.
/nspect an#les and feet for color, temperature, s#in integrityL note any
ulcerationsL chec# for hair loss, trophic s#in changes, hypertrophic
nails.
>2ource. (irsch ', (as#al OP, (ert"er <=, et al. 'CCM'(' $00)
guidelines for the management of patients %ith peripheral arterial disease.?
67',*862 9: ';<9=,'8//62
'symmetric blood pressures seen in coarctation of the aorta and dissecting
aortic aneurysm
'=,2
/nspect both arms from the fingertips to the shoulders. <ote.
A heir si"e, symmetry, and any s%elling
67',*862 9: ';<9=,'8//62
8ymphedema of the arm and hand may follo% axillary node dissection and
radiation therapy.
A he venous pattern
67',*862 9: ';<9=,'8//62
*rominent veins in an edematous arm suggest venous obstruction.
A he color of the s#in and nail beds and the texture of the s#in
*alpate the radial pulse %ith the pads of your fingers on the flexor surface of
the %rist laterally. *artially flexing the patientKs %rist may help you feel this
pulse. Compare the pulses in both arms.
67',*862 9: ';<9=,'8//62
/n =aynaudKs disease, %rist pulses are typically normal, but spasm of more
distal arteries causes episodes of sharply demarcated pallor of the fingers
>see able 1$31, *ainful *eripheral 4ascular -isorders and heir ,imics, pp.
1H131H)?.
here are several systems for grading the amplitude of the arterial pulses.
9ne system uses a scale of 0 to 3, as belo%.
3
Iou should chec# to see %hat
scale your institution uses.
67',*862 9: ';<9=,'8//62
<ote that if an artery is %idely dilated, it is aneurysmal.
Rec"mmene Grain$ "! Pulses
1
3R ;ounding
$R ;ris#, expected >normal?
1R -iminished, %ea#er than expected
0 'bsent, unable to palpate
67',*862 9: ';<9=,'8//62
;ounding carotid, radial, and femoral pulses in aortic insufficiencyL
asymmetric diminished pulses in arterial occlusion from atherosclerosis or
embolism
/f you suspect arterial insufficiency, feel for the brachial pulse. :lex the
patientKs elbo% slightly, and palpate the artery 0ust medial to the biceps
tendon at the antecubital crease. he brachial artery can also be felt higher in
the arm in the groove bet%een the biceps and triceps muscles.
:eel for one or more epitrochlear nodes. 5ith the patientKs elbo% flexed to
about H0S and the forearm supported by your hand, reach around behind the
arm and feel in the groove bet%een the biceps and triceps muscles, about 3
cm above the medial epicondyle. /f a node is present, note its si"e,
consistency, and tenderness.
67',*862 9: ';<9=,'8//62
'n enlarged epitrochlear node may arise from local or distal infection or
may be associated %ith generali"ed lymphadenopathy.
6pitrochlear nodes are difficult or impossible to identify in most normal
people.
86+2
he patient should be lying do%n and draped so that the external genitalia
are covered and the legs fully exposed. ' good examination is impossible
through stoc#ings or soc#sT
/nspect both legs from the groin and buttoc#s to the feet. <ote.
A heir si"e, symmetry, and any s%elling
2ee able 1$33, Chronic /nsufficiency of 'rteries and 4eins >p. 1HC?.
A he venous pattern and any venous enlargement
A 'ny pigmentation, rashes, scars, or ulcers
2ee able 1$31, Common Blcers of the 'n#les and :eet >p. 1HD?.
A he color and texture of the s#in, the color of the nail beds, and the
distribution of hair on the lo%er legs, feet, and toes.
*alpate the superficial inguinal nodes, including both the hori"ontal and the
vertical groups. <ote their si"e, consistency, and discreteness, and note any
tenderness. <ontender, discrete inguinal nodes up to 1 cm or even $ cm in
diameter are fre&uently palpable in normal people.
67',*862 9: ';<9=,'8//62
8ymphadenopathy refers to enlargement of the nodes, %ith or %ithout
tenderness. ry to distinguish bet%een local and generali"ed
lymphadenopathy, respectively, by finding either >1? a causative lesion in the
drainage area or >$? enlarged nodes in at least t%o other noncontiguous
lymph node regions.
*.1D1
*alpate the pulses to assess the arterial circulation.
A he femoral pulse. *ress deeply, belo% the inguinal ligament and about
mid%ay bet%een the anterior superior iliac spine and the symphysis pubis.
's in deep abdominal palpation, the use of t%o hands, one on top of the
other, may facilitate this examination, especially in obese patients.
67',*862 9: ';<9=,'8//62
' diminished or absent pulse indicates partial or complete occlusion
proximallyL for example, at the aortic or iliac level, all pulses distal to the
occlusion are typically affected. Chronic arterial occlusion, usually from
atherosclerosis, causes intermittent claudication >p. 1H1?, postural color
changes >p. 1H0?, and trophic changes in the s#in >p. 1H0?.
67',*862 9: ';<9=,'8//62
'n exaggerated, %idened femoral pulse suggests a femoral aneurysm, a
pathologic dilatation of the artery.
A he popliteal pulse. he patientKs #nee should be some%hat flexed, %ith
the leg relaxed. *lace the fingertips of both hands so that they 0ust meet in
the midline behind the #nee and press them deeply into the popliteal fossa.
he popliteal pulse is often more difficult to find than other pulses. /t is
deeper and feels more diffuse.
67',*862 9: ';<9=,'8//62
'n exaggerated, %idened popliteal pulse suggests an aneurysm of the
popliteal artery. *opliteal and femoral aneurysms are not common. hey are
usually caused by atherosclerosis and occur primarily in men older than )0
years.
*.1D)
/f you cannot feel the popliteal pulse %ith this approach, try %ith the patient
prone. :lex the patientKs #nee to about H0S, let the lo%er leg relax against
your shoulder or upper arm, and press your t%o thumbs deeply into the
popliteal fossa.
67',*862 9: ';<9=,'8//62
'therosclerosis >arteriosclerosis obliterans? most commonly obstructs
arterial circulation in the thigh. he femoral pulse is then normal, the
popliteal decreased or absent.
A he dorsalis pedis pulse. :eel the dorsum of the foot >not the an#le? 0ust
lateral to the extensor tendon of the great toe. /f you cannot feel a pulse,
explore the dorsum of the foot more laterally.
67',*862 9: ';<9=,'8//62
he dorsalis pedis artery may be congenitally absent or may branch higher
in the an#le. 2earch for a pulse more laterally.
67',*862 9: ';<9=,'8//62
-ecreased or absent pedal pulses >assuming a %arm environment? %ith
normal femoral and popliteal pulses suggest occlusive disease in the lo%er
popliteal artery or its branchesJoften seen in diabetes mellitus.
A he posterior tibial pulse. Curve your fingers behind and slightly belo% the
medial malleolus of the an#le. >his pulse may be hard to feel in a fat or
edematous an#le.?
67',*862 9: ';<9=,'8//62
2udden arterial occlusion from embolism or thrombosis causes pain and
numbness or tingling. he limb distal to the occlusion becomes cold, pale,
and pulseless. 6mergency treatment is re&uired. /f collateral circulation is
good, only numbness and coolness may result.
*.1D!
/*2 :9= :668/<+ -/::/CB8 *B8262
*osition your body and examining hand comfortablyL a%#%ard
positions decrease your tactile sensitivity.
*lace your hand properly and linger there, varying the pressure of
your fingers to pic# up a %ea# pulsation. /f unsuccessful, then explore
the area deliberately.
-o not confuse the patientKs pulse %ith your o%n pulsating fingertips.
/f you are unsure, count your o%n heart rate and compare it %ith the
patientKs. he rates are usually different. Iour carotid pulse is
convenient for this comparison.
<ote the temperature of the feet and legs %ith the bac#s of your fingers.
Compare one side %ith the other. ;ilateral coldness is most often caused by
a cold environment or anxiety.
67',*862 9: ';<9=,'8//62
Coldness, especially %hen unilateral or associated %ith other signs, suggests
arterial insufficiency from inade&uate arterial circulation.
8oo# for edema. Compare one foot and leg %ith the other, noting their
relative si"e and the prominence of veins, tendons, and bones.
67',*862 9: ';<9=,'8//62
6dema causes s%elling that may obscure the veins, tendons, and bony
prominences.
*.1DC
Chec# for pitting edema. *ress firmly but gently %ith your thumb for at least
) seconds >1? over the dorsum of each foot, >$? behind each medial
malleolus, and >3? over the shins. 8oo# for pittingJa depression caused by
pressure from your thumb. <ormally there is none. he severity of edema is
graded on a four3point scale, from slight to very mar#ed.
2ee able 1$3), 2ome *eripheral Causes of 6dema >p. 1HH?.
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2ho%n belo% is 3R pitting edema.
/f you suspect edema, measure the legs to identify the edema and to follo%
its course. 5ith a flexible tape, measure >1? the forefoot, >$? the smallest
possible circumference above the an#le, >3? the largest circumference at the
calf, and >1? the midthigh, a measured distance above the patella %ith the
#nee extended. Compare one side %ith the other. ' difference of more than 1
cm 0ust above the an#le or $ cm at the calf is unusual in normal people and
suggests edema.
67',*862 9: ';<9=,'8//62
Conditions such as muscular atrophy can also cause different circumferences
in the legs.
/f edema is present, loo# for possible causes in the peripheral vascular
system. hese include >1? recent deep venous thrombosis, >$? chronic
venous insufficiency from previous deep venous thrombosis or
incompetence of the venous valves, and >3? lymphedema. <ote the extent of
the s%elling. (o% far up the leg does it goU
67',*862 9: ';<9=,'8//62
/n deep venous thrombosis, the extent of edema suggests the location of the
occlusion. the popliteal vein %hen the lo%er leg or the an#le is s%ollenL the
iliofemoral veins %hen the entire leg is s%ollen.
/s the s%elling unilateral or bilateralU 're the veins unusually prominentU
67',*862 9: ';<9=,'8//62
4enous distention suggests a venous cause of edema.
*.1DD
ry to identify any venous tenderness that may accompany deep venous
thrombosis. *alpate the groin 0ust medial to the femoral pulse for tenderness
of the femoral vein. <ext, %ith the patientKs leg flexed at the #nee and
relaxed, palpate the calf. 5ith your fingerpads, gently compress the calf
muscles against the tibia, and search for any tenderness or cords. -eep
venous thrombosis, ho%ever, may have no demonstrable signs, and
diagnosis often depends on high clinical suspicion and other testing.
67',*862 9: ';<9=,'8//62
' painful, pale s%ollen leg, together %ith tenderness in the groin over the
femoral vein, suggests deep iliofemoral thrombosis. 9nly half of patients
%ith deep venous thrombosis in the calf have tenderness and cords deep in
the calf. Calf tenderness is nonspecific and may be present %ithout
thrombosis.
<ote the color of the s#in.
A /s there a local area of rednessU /f so, note its temperature, and gently try to
feel the firm cord of a thrombosed vein in the area. he calf is most often
involved.
67',*862 9: ';<9=,'8//62
8ocal s%elling, redness, %armth, and a subcutaneous cord suggest
superficial thrombophlebitis.
A 're there bro%nish areas near the an#lesU
67',*862 9: ';<9=,'8//62
;ro%nish discoloration or ulcers 0ust above the malleolus suggest chronic
venous insufficiency.
A <ote any ulcers in the s#in. 5here are theyU
A :eel the thic#ness of the s#in.
67',*862 9: ';<9=,'8//62
hic#ened bra%ny s#in suggests lymphedema and advanced venous
insufficiency.
's# the patient to stand, and inspect the saphenous system for varicosities.
he standing posture allo%s any varicosities to fill %ith blood and ma#es
them visible. Iou can easily miss them %hen the patient is in a supine
position. :eel for any varicosities, noting any signs of thrombophlebitis.
67',*862 9: ';<9=,'8//62
4aricose veins are dilated and tortuous. heir %alls may feel some%hat
thic#ened. ,any varicose veins can be seen in the leg on p. 1H1.
2*6C/'8 6C(</QB62
E2aluatin$ the Arterial Supply t" the Han&
/f you suspect arterial insufficiency in the arm or hand, try to feel the ulnar
pulse as %ell as the radial and brachial pulses. :eel for it deeply on the
flexor surface of the %rist medially. *artially flexing the patientKs %rist may
help you. he pulse of a normal ulnar artery, ho%ever, may not be palpable.
67',*862 9: ';<9=,'8//62
'rterial occlusive disease is much less common in the arms than in the legs.
'bsent or diminished pulses at the %rist are found in acute embolic
occlusion and in ;uergerKs disease, or thromboangiitis obliterans.
he 'llen test gives further information. his test is also useful to ensure the
patency of the ulnar artery before puncturing the radial artery for blood
samples. he patient should rest %ith hands in lap, palms up.
's# the patient to ma#e a tight fist %ith one handL then compress both radial
and ulnar arteries firmly bet%een your thumbs and fingers.
<ext, as# the patient to open the hand into a relaxed, slightly flexed position.
he palm is pale.
67',*862 9: ';<9=,'8//62
6xtending the hand fully may cause pallor and a falsely positive test.
=elease your pressure over the ulnar artery. /f the ulnar artery is patent, the
palm flushes %ithin about 3 to ) seconds.
67',*862 9: ';<9=,'8//62
*ersisting pallor indicates occlusion of the ulnar artery or its distal branches.
*atency of the radial artery may be tested by releasing the radial artery %hile
still compressing the ulnar artery.
P"stural '"l"r 'han$es "! 'hr"nic Arterial Insu!!iciency.
/f pain or diminished pulses suggest arterial insufficiency, loo# for postural
color changes. =aise both legs, as sho%n at the right, to about !0S until
maximal pallor of the feet developsJusually %ithin a minute. /n light3
s#inned persons, either maintenance of normal color, as seen in this right
foot, or slight pallor is normal.
67',*862 9: ';<9=,'8//62
,ar#ed pallor on elevation suggests arterial insufficiency.
hen as# the patient to sit up %ith legs dangling do%n. Compare both feet,
noting the time re&uired for.
A =eturn of pin#ness to the s#in, normally about 10 seconds or less
A :illing of the veins of the feet and an#les, normally about 1) seconds
his right foot has normal color and the veins on the foot have filled. hese
normal responses suggest an ade&uate circulation.
67',*862 9: ';<9=,'8//62
he foot above is still pale, and the veins are 0ust starting to fillJsigns of
arterial insufficiency.
8oo# for any unusual rubor >dus#y redness? to replace the pallor of the
dependent foot. =ubor may ta#e a minute or more to appear.
<ormal responses accompanied by diminished arterial pulses suggest that a
good collateral circulation has developed around an arterial occlusion.
Color changes may be difficult to see in dar#er3s#inned persons. /nspect the
soles of the feet for these changes, and use tangential lighting to see the
veins.
67',*862 9: ';<9=,'8//62
*ersisting rubor on dependency suggests arterial insufficiency >see p. 1HD?.
5hen veins are incompetent, dependent rubor and the timing of color return
and venous filling are not reliable tests of arterial insufficiency.
*.1H1
Mappin$ Varic"se Veins&
Iou can map out the course and connections of varicose veins by
transmitting pressure %aves along the blood3filled veins. 5ith the patient
standing, place your palpating fingers gently on a vein and, %ith your other
hand belo% it, compress the vein sharply. :eel for a pressure %ave
transmitted to the fingers of your upper hand. ' palpable pressure %ave
indicates that the t%o parts of the vein are connected.
' %ave may also be transmitted do%n%ard, but not as easily.
6valuating the Competency of 4enous 4alves.
;y the retrograde filling >rendelenburg? test, you can assess the valvular
competency in both the communicating veins and the saphenous system.
2tart %ith the patient supine. 6levate one leg to about H0S to empty it of
venous blood.
<ext, occlude the great saphenous vein in the upper thigh by manual
compression, using enough pressure to occlude this vein but not the deeper
vessels. 's# the patient to stand. 5hile you #eep the vein occluded, %atch
for venous filling in the leg. <ormally the saphenous vein fills from belo%,
ta#ing about 3) seconds as blood flo%s through the capillary bed into the
venous system.
67',*862 9: ';<9=,'8//62
=apid filling of the superficial veins %hile the saphenous vein is occluded
indicates incompetent valves in the communicating veins. ;lood flo%s
&uic#ly in a retrograde direction from the deep to the saphenous system.
'fter the patient stands for $0 seconds, release the compression and loo# for
sudden additional venous filling. <ormally there is noneL competent valves
in the saphenous vein bloc# retrograde flo%. 2lo% venous filling continues.
67',*862 9: ';<9=,'8//62
2udden additional filling of superficial veins after release of compression
indicates incompetent valves in the saphenous vein.
5hen both steps of this test are normal, the response is termed
negativenegative. <egative3positive and positive3negative responses may
also occur.
67',*862 9: ';<9=,'8//62
5hen both steps are abnormal, the test is positive3positive.
*.1H$
=6C9=-/<+ I9B= :/<-/<+2
<ote that initially you may use sentences to describe your findingsL later you
%ill use phrases. he style belo% contains phrases appropriate for most
%rite3ups. =ecall that the %ritten description of lymph nodes appears in
Chapter C, he (ead and <ec# >see p. $1)?. 8i#e%ise, assessment of the
carotid pulse is recorded in Chapter H, he Cardiovascular 2ystem >see p.
3C1?.
=ecording the *hysical 6xaminationJhe *eripheral 4ascular 2ystem
6xtremities are %arm and %ithout edema. <o varicosities or stasis changes.
Calves are supple and nontender. <o femoral or abdominal bruits. ;rachial,
radial, femoral, popliteal, dorsalis pedis >-*?, and posterior tibial >*?
pulses are $R and symmetric.
9=
6xtremities are pale belo% the midcalf, %ith notable hair loss. =ubor noted
%hen legs dependent but no edema or ulceration. ;ilateral femoral bruitsL no
abdominal bruits heard. ;rachial and radial pulses $RL femoral, popliteal, -*
and * pulses 1R. >'lternatively, pulses can be recorded as belo%.?
Raial +rachial (em"ral P"pliteal D"rsalis Peis P"steri"r Ti3ial
=

$R $R 1R 1R 1R 1R
8$R $R 1R 1R 1R 1R
67',*862 9: ';<9=,'8//62
2uggests atherosclerotic peripheral arterial disease